A problem with a healthcare insurance company

Samoerai

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Ada ada aja ...
So far I have encountered only problems in Indonesia. Now with a healthcare insurance company.

I hope someone in this Forum can help me with 'how to handle this', because it's costing me already a lot and maybe more. It's an interesting case for those who like 'solving complex problems'.

If the moderators think that this is too private, and will get me in problems later, please feel free to delete this post or warn me.

The case is as follow and I start at the beginning, which is the root of my problem with this company.

In October 2021 I got really sick with high fever and went to Siloam Hospital Karawaci.
In the midst of Covid-19 pandamic.

Not knowing the cause of the high fever, the doctors checked of course for Covid-19, did some bloodtest and ct-scan of my lungs. After a lot of test the results are: Demam Bedarah (for sure) and maybe also Tyfus.

On the ct-scans there are also some -old age- related signs of cysts on he kidneys and other things, not very serious.
According to the doctor, all most everyone older than 50 years has these things.
I was not treated for this and also until now I had/have no symptoms or illnesses related to the things on the ct-scans.

These ct-scans play a roll in the problem I have with this company.
Bear with me ...

I have a health care insurance In Holland, but the premium is getting higher and higher and I decided that I want to change to a healthcare insurance in Indonesia.

So on 17 December 2022 I applied for a healthcare insurance. As is the procedure here, an agent came to me.

This company asked some questions, around 10 on a standard questionnaire and I answered these questions honestly.
Together with the agent we filled in this questionnaire and we checked the answers carefully, on my request, because the questions are in bahasa Indonesia and I cannot understand them. So the agent translated them to me.
All answers are checked 'NO' except for the treatment in the hospital for the demam berdarah, as virus treatment.

The company accepted me based on the questionnaire very fast and no medical check was necessary. This because there was a PROMO/Campaign at that time, saying no medical check necessary. So, from that moment on in January 2023 I paid the monthly premium: 4,2 juta for a unit-link medical care health insurance.

In April, last month, because of some discussions with other expats I met, about coverage for 1-person hospital rooms. I checked my polis, terms and conditions and came accidentally across a paragraph in the application form, saying:

Jika ditemukan kondisi yang telah ada sebelumnya (pre-existing condition) yang tidak diberitahukan oleh Pemegang Polis atau Tertanggung sesuai ketentuan Polis Asuransi Dasar atau Asuransi Tambahan (jika ada). Pre-existing condition adalah kondisi di mana segala jenis penyakit, cedera atau ketidakmampuan yang tanda atau gejalanya diketahui atau tidak diketahui oleh Pemegang Polis atau Tertanggung, baik telah ataupun belum didiagnosis oleh Dokter, baik telah ataupun belum mendapatkan perawatan/pengobatan/saran/konsultasi dari Dokter, terlepas dari pengobatan sebenarnya telah ataupun belum dilakukan, yang terjadi sebelum Tanggal Mulai Pertanggungan, atau tanggal Pemulihan Polis yang terakhir, tergantung pada
tanggal yang paling akhir sesuai dengan ketentuan Polis. Dalam hal Pemegang Polis atau Tertanggung memberitahukan kondisi yang telah ada sebelumnya (pre-existing condition), maka Penanggung akan melakukan penilaian terhadap kondisi tersebut yang mana pengajuan ilustrasi ini dapat diterima atau perlu penyesuaian, atau ditolak.


So I asked my agent about this and I remembered the ct-scans and thinking this may cause some problems in the future. So I decided to sent in the reports of the ct-scans as an 'addendum' to this company last month April 2023.

A couple of days ago I got the decision of the underwriter, saying:

Data tersebut belum pernah disampaikan sebelumnya kepada kami saat pemrosesan
Surat Pengajuan Asuransi Jiwa (SPAJ) pada 27 Januari 2023. Seandainya data tersebut
kami ketahui pada waktu pemrosesan SPAJ, maka keputusan atas penilaian seleksi risiko
(underwriting) yang kami berikan atas Polis tersebut akan berbeda.
Mengacu pada Pasal 5 Ketentuan Umum Polis mengenai Dasar Pertanggungan, maka:
1. Seharusnya Polis dengan sendirinya batal dan dianggap tidak pernah berlaku.
2. Kami tidak berkewajiban untuk menanggung risiko apapun atas jiwa Tertanggung.
3. Dana pembatalan Polis dihitung berdasarkan rumus sebagai berikut:

K = M – (B + N + S) + H
di mana:
K: Jumlah yang harus Pemegang Polis/Penerima Manfaat bayarkan kepada
Penanggung.
M: Manfaat Asuransi yang telah dibayarkan kepada Pemegang Polis/Penerima
Manfaat.
B: Biaya Asuransi yang telah dibayarkan oleh Pemegang Polis sejak Tanggal Mulai
Pertanggungan.
N: Nilai Tunai Polis sebagai (bagian) Manfaat Asuransi.
S: Titipan Premi pada Polis.
H: Kewajiban yang tertunggak dari Pemegang Polis kepada Penanggung yang tidak
diperhitungkan dengan pembayaran Manfaat Asuransi (apabila ada).

Berdasarkan kriteria dan Ketentuan Polis, kami dapat memberikan penawaran kebijakan
agar Polis tetap aktif dengan keputusan substandard sebagai berikut:
1. Dikenakan tambahan Biaya Asuransi untuk manfaat Asuransi Dasar (kode rating: L5).
2. Manfaat Asuransi Tambahan tidak dapat kami berikan.
3. Keputusan substandard tersebut berlaku efektif sejak tanggal Polis diterbitkan.
4. Atas perubahan tersebut, terlampir Endosemen untuk dilekatkan pada Polis dan
merupakan bagian yang tak terpisahkan.


So, as I understand this company denies me now the healthcare insurance, only the life insurance (only the unit).
And this is my problem now.

I want to fight this decision of the underwriter. How to do that?

I think like this.

So, I need to know exactly what the definition is for Pre-existing condition.
Is it indeed that I had to give them the results of my ct-scans at the time of application?

Because this company now is blaming me for not telling them about the results on the ct-scan. CT-scans more than 1 year ago. The ct-scan were not on the top of my mind, when I applied for the health insurance, because I am not sick, don't have any symptoms and I feel very healthy (like a 'spring chicken').

So first of all, I think they can not blame me for not telling them, because

1. There is no question about "Do you have a pre-existing condition?"
2. This question about pre-existing conditions is not in the questionnaire.
3. The agent didn't ask me this during the application when he visit me.
4. Even if the question came up "Do you have a pre-existing condition? Do I have to tell them about the scan?"
5. But the question was not asked, so did I have to give them my ct-scan reports?
6. What is the definition of a pre-existing condition?
7. Does the things, like cysts on kidney because of old age, fall under this definition?
8. Because I have no symptoms nor am I sick.

And now the underwriter denies me the healthcare insurance. Meaning also I cannot get a other healthcare insurance in Indonesia, because other healthcare insurances will ask the question "Did an other health care insurance ever denied you an insurance?"

My point is:
I am in this situation. The underwriter now denies me a (unit link) healthcare insurance.
After they already accepted me in December 2022 very fast, because of a PROMO saying no medical check necessary. At this moment I have already paid 5 x premium of 4,2 juta, for nothing. as it turns out now.
The company blaming me for not telling them about the pre-existing conditions. But can they blame me based on their application process? Not asking about pre-existing conditions and the definition of pre-existing condition?

What other things I will encounter, ending this insurance?

Many thanks in advance for helping me.
 
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You won't win so don't waste your time and money
Pre existing condition is never covered. Especially for something like this.
Cancel it and find a better one. But none will cover your situation.
Sorry
They will blame you for not telling them and at best just fire the salesgirl
 
Agree with snpark. No way to win this. Pre existing condition clauses are common everywhere. Used to be the same in the US until federal law was changed becuase of companies changing insurance providers so oftern. Before that law was changed, I had to go a year without coverage for my existing condition at the time through no fault of my own.
 
Yep, that’s the infamous small print.

Why did you go for the mutual fund investment combination btw, why not just health insurance?

And I do think it’s okay to mention the name of the insurance company (Allianz? Prudential?).
 
Why did you go for the mutual fund investment combination btw, why not just health insurance?
A unit-link healthcare insurance has some advantages compared to a classic healthcare insurance. One of them is that (unless the stock market dips) the premium will not increase. The premium of the classic insurance, i.e. without unit-link, is lower in the first years than the 'unit-link' insurance, but will increase every year by about 12 - 15 %. So after about 6 years, the premium you have to pay has doubled.
 
The principles by which many if not most insurance companies operate are quite simple.
Advertise seductively about what a great service they offer.
Accept payments promptly.
Avoid payouts wherever possible.

In Australia it has been common for people with house insurance believing they were covered against flooding. After being flooded their claims were denied because a number of insurance companies claimed the damage was caused by rain not flooding.

A friend had taken the most expensive comprehensive insurance for his mother. While attending a private hospital for a check up she had a heart attack and was hospitalized. She stayed in intensive care for 15 days and then there was a bill for $30,000 with the insurance company saying because she had not been transferred to a public hospital a few days after the heart attack then she was not covered. My seriously wealthy friend was outraged and went to court and won the case but most of us would be intimidated by the probable legal costs. It is worthwhile for insurance companies to spend large amounts of money defending litigation as a kind of warning to us commoners not to take them on.

Sorry to see you in this distressing situation. Perhaps a better remedy might be to save what you would normally pay for insurance and have this as a fund against any future medical care. Once you move beyond 70 it is difficult to find affordable insurance anyway. Good luck.
 
Incidentally, if you could get a newspaper or TV coverage for your story you might get the usual PR response from the company saying it was due to a misunderstanding and then accepting the claim. Bad PR is something many companies take very seriously.
 
Incidentally, if you could get a newspaper or TV coverage for your story you might get the usual PR response from the company saying it was due to a misunderstanding and then accepting the claim. Bad PR is something many companies take very seriously.
Good idea .. bad publicity would gain some traction maybe ..
 
Bad PR is something many companies take very seriously.
I am busy with writing Dos & Don'ts + Tips & Tricks when one wants to move to Indonesia, about: tax, insurances, buying property etc.

Now, I have to add a whole new paragraph about the 'pre-existing conditions' ... aduh.
 
But then again one must be careful it doesn't come back to bite you on the ass
If he didn't reveal his pre existing conditions ?
He should at least written himself on the questionnaire
11. CRT scans attached from recent medical for routine checkup showing negative for cancer

Then it would be still up to them to accept you or not
After all, cancer is genetic mostly so we all have pre existing conditions inbred into us.
MS or cancer (except from smoking) isn't something you catch. Like an STD
 
Prudential aren't the best for sure

Maybe cancel. Get your money back? 4.7jt a month is high. I'm with Allianz and pay 1.7jt a month and I'm in my 50's (non smoker) on their full package unit linked Inc covid (remember that?!)
Try allianz
 
If he didn't reveal his pre existing conditions ?
That's my point in my post. There is no question about 'pre-existing conditions' in the questionnaire.
And the ct-scans (more than 1 year ago) are not on the top of my mind (because I am not suffering from the cysts on my kidneys etc.)
 
Last edited:
Prudential aren't the best for sure

Maybe cancel. Get your money back? 4.7jt a month is high. I'm with Allianz and pay 1.7jt a month and I'm in my 50's (non smoker) on their full package unit linked Inc covid (remember that?!)
Try allianz
Cancelling is easier said than done ... according to the terms, I maybe have to pay 1 more year or more, because of the unit-link ... I don't know.

Also: Allianz will not accept me now, because there is a question about "did another insurance company denied you before"
 
That's my point in my post. There is no question about 'pre-existing conditions' in the questionnaire.
And the ct-scan (more than 1 year ago) are not on the top of my mind (because I am not suffering from the cysts on my kidneys etc.)

Yes but they will say you didn't read the form correctly.
 
Cancelling is easier said than done ... according to the terms, I maybe have to pay 1 more year or more, because of the unit-link ... I don't know.

Also: Allianz will not accept me now, because there is a question about "did another insurance company denied you before"
No they didn't deny you. I mean you are paying premiums right?
The accepted you and you have a policy number. So you were not denied.
 
No they didn't deny you. I mean you are paying premiums right?
The accepted you and you have a policy number. So you were not denied.
Now Prudential does deny me, because of the reports I add a month ago (addendum):

Berdasarkan kriteria dan Ketentuan Polis, kami dapat memberikan penawaran kebijakan
agar Polis tetap aktif dengan keputusan substandard sebagai berikut:
1. Dikenakan tambahan Biaya Asuransi untuk manfaat Asuransi Dasar (kode rating: L5).
2. Manfaat Asuransi Tambahan tidak dapat kami berikan.
3. Keputusan substandard tersebut berlaku efektif sejak tanggal Polis diterbitkan.
4. Atas perubahan tersebut, terlampir Endosemen untuk dilekatkan pada Polis dan
merupakan bagian yang tak terpisahkan.
 
Good idea .. bad publicity would gain some traction maybe ..
I wouldn't count on it. I found a flaw in all Apple products in Indonesia that would blow up in the west. Here nobody cares and the problem still exists to this day. Tried to take the info to the media and even a couple of government officials. Litterly no one cared.
 
Insurances companies frequently amend their policies to avoid claims. In the case mentioned above, regarding my friend suing the insurance company, the company had made amendments after my friend had taken a policy and according to their legal argument this had negated any obligation to payout in this particular case. They argued that it behoves clients to review company policies as if clients are likely every other day to check for new amendments. The court rejected that particular argument when finding against the insurance company.
 

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